By December 31st $20.00 UNDER 5 FREE
After December 31st $25.00
Registration Form (make checks payable to: Rebecca Williams-Thomas / Frostbite)
Name:____________________________________________________ Age: (as of 1/28/2011) _______
Date of Birth:_______/_______/_______ Gender:_______________
Address:____________________________________________________________________________________
City:___________________________ State:__________________________ Zip:______________
Email:__________________________________________
Telephone #:____________________________________
Shirt Size (please circle) Small Medium Large Extra Large
Method of Payment (please circle) Check Cash
Credit Card Information [ ] MasterCard [ ] VISA
Name on Card:_______________________________________________________
Email:______________________________________________________________
Address:_____________________________________________________________________________
_________________________________________________________
Contact Person:_____________________________________ Phone/Fax:________________________
____________________________________
Card Number ____ ____ ____ ____--____ ____ ____ ____--____ ____ ____ ____--____ ____ ________
Expiration Date: ____________/_____________ 3-Digit Security Code ______________
Send registration form to: Benefitting
Rebecca-Williams Thomas
Aboard (Frostbite 5K)
35 Wilson Street, Suite 100
Pittsburgh PA 15223
NO REFUNDS
After December 31st $25.00
Registration Form (make checks payable to: Rebecca Williams-Thomas / Frostbite)
Name:____________________________________________________ Age: (as of 1/28/2011) _______
Date of Birth:_______/_______/_______ Gender:_______________
Address:____________________________________________________________________________________
City:___________________________ State:__________________________ Zip:______________
Email:__________________________________________
Telephone #:____________________________________
Shirt Size (please circle) Small Medium Large Extra Large
Method of Payment (please circle) Check Cash
Credit Card Information [ ] MasterCard [ ] VISA
Name on Card:_______________________________________________________
Email:______________________________________________________________
Address:_____________________________________________________________________________
_________________________________________________________
Contact Person:_____________________________________ Phone/Fax:________________________
____________________________________
Card Number ____ ____ ____ ____--____ ____ ____ ____--____ ____ ____ ____--____ ____ ________
Expiration Date: ____________/_____________ 3-Digit Security Code ______________
Send registration form to: Benefitting
Rebecca-Williams Thomas
Aboard (Frostbite 5K)
35 Wilson Street, Suite 100
Pittsburgh PA 15223
NO REFUNDS
